APPLICATION FOR A BARANGAY PROTECTION ORDER (BPO)

Petitioner ____________________________ Respondent ___________________________

Address ______________________________ Address ______________________________
Description of Relationship ___________________________________________________
Statement of circumstances of abuse :

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May I request for a counsel because I am economically and financially constrained to hire
a lawyer to protect my rights under the law.

Furthermore, I hereby request for waiver of payment of application fees until hearing of
my case and that I am attesting to the fact that I have not applied for any Protection Order in any
court.

______________________________
Petitioner/Applicant

SUBSCRIBED AND SWORN to before me this _________________ in Quezon City

Metro Manila.

______________________
Punong Barangay
 OFFICE OF THE PUNONG BARANGAY

________________________,
Petitioner,

-against- BPO NO. 01- _

________________________,
Respondent.
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BARANGAY PROTECTION ORDER

This office after determining the application of petitioner for a Barangay

Protection Order to be meritorious, the same is hereby granted. Therefore ,
respondent is hereby ordered to desist from committing acts under Section 5 (a)
and (b) of Republic Act 9262 or the Violence Against Women and their Children
Act , as follows:

(a) Causing physical harm to the woman or her child;

(b) Threatening to cause the woman or her child physical harm; and

(c) Prohibition of the respondent from harassing, annoying, telephoning,

contacting or otherwise communicating with the petitioner, directly or indirectly.

"VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW."

SO ORDERED.

________________, 2011.

HON. LORENZO S. REYES V

Punong Barangay